Provider Demographics
NPI:1609450311
Name:HARRISON, DOMENIQUE (LMFT)
Entity type:Individual
Prefix:
First Name:DOMENIQUE
Middle Name:
Last Name:HARRISON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12851 RUBENS AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-6539
Mailing Address - Country:US
Mailing Address - Phone:973-477-4350
Mailing Address - Fax:
Practice Address - Street 1:12851 RUBENS AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-6539
Practice Address - Country:US
Practice Address - Phone:973-477-4350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-09
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA138559106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist